By Michelle Crouch, AARP January 2022
Nearly half of older adults take at least five drugs daily, and the side effects can add up.
In March 2021, Mary Ann Johnson of Warwick, Rhode Island, reached down to pick something up off the floor and suddenly felt dizzy. She tried to get to the couch but tripped on a chair and fell, and the chair toppled on top of her. Johnson ended up with a knee fracture and a deep gash on her forehead.
It wasn’t the first time Johnson had fallen in recent months, and she also constantly felt tired and weak. Fortunately, Johnson’s doctor recognized that dizziness and fatigue can sometimes be a medication side effect, so he asked a clinical pharmacist to review Johnson’s prescriptions. Johnson, 70, was taking more than 16 medications, including several that affect the central nervous system (the brain and spinal cord).
Pharmacist Brianna Kimball recommended that Johnson reduce the dose of one of her prescriptions and stop taking three others altogether. It made a difference.
“I’m doing fine without them,” Johnson says, “and I haven’t had the lightheadedness.”
More pills than ever
Experts have warned for years about the dangers of taking five or more drugs at the same time — a phenomenon known as polypharmacy. Yet over the past two decades, the percentage of people age 65 and older taking five or more prescriptions has tripled, from 14 to 42 percent, according to data from the Centers for Disease Control and Prevention (CDC). Nearly 20 percent of older adults take 10 drugs or more, according to the Lown Institute.
Use of over-the-counter drugs and dietary supplements is also at an all-time high, Council for Responsible Nutrition data shows. While medicines can be critical for keeping us healthy, most tend to have side effects. And the more medications you take, the higher your risk of experiencing a problem or a dangerous interaction, says Sabine von Preyss-Friedman, M.D., a geriatric specialist and chief medical officer for Avalon Health Care Group, whose services include assisted living and home health care.
Every day, 750 adults age 65 or older are hospitalized for serious side effects from a medication, according to the Lown Institute. One Lown Institute study found that you are 88 percent more likely to seek care for a drug complication or side effect if you take five or more medications.
Other research shows that your fall risk increases 7 percent for each medication you take.
“It’s to the point that taking too many medications becomes an illness in and of itself,” von Preyss-Friedman says.
Older adults at greater risk
Older adults accumulate medications for a variety of reasons. It’s partly because they are living longer and are more likely to have chronic diseases that require medical management. But it’s also because when patients report a symptom, doctors have a tendency to prescribe a new medication first, rather than recommend a lifestyle change or consider whether the symptom could be caused by a different drug.
“It is always easier to just add another medication rather than take one away,” von Preyss-Friedman says.
Adults who see a few different doctors to manage their chronic conditions run the risk of having each specialist prescribe a different medication without taking into account the overall effect on the patient, says Hedva Barenholtz Levy, president of the American Society of Consultant Pharmacists and an independent pharmacist in St. Louis.
“I had one 74-year-old patient who had three prescribing doctors and 26 medications,” Levy says. “He was taking medications the primary doctor didn’t even know the other doctors had prescribed, and he was having multiple adverse drug reactions, including drowsiness and inability to concentrate.”
It’s also common for older adults to continue taking a medication for years or decades, without stopping to consider whether it’s still necessary, whether it could interact with new prescriptions or whether the dosage is still appropriate.
Medication sensitivity increases with age
Because kidney function declines as you age — and drugs are filtered by the kidneys — it’s not unusual for a medication you have been taking for years to suddenly start causing side effects, says Ardeshir Hashmi, M.D., section chief of Cleveland Clinic’s Center for Geriatric Medicine.
“If you don’t reduce the dosage as you get older, the medication may actually be hanging around in your system, and then you take another dose and then another, and they keep cumulatively increasing until you’re at risk of drug toxicity or profound side effects that you didn’t have previously from the medicine,” Hashmi explains.
Sometimes, side effects from a medication are misdiagnosed as a new problem, triggering more prescriptions — this is known as a “prescribing cascade.”
For example, let’s say you take a medicine for heartburn and one day you notice that you’re forgetting things. If a doctor doesn’t recognize that your cognition problems might be a side effect from the heartburn medication, he or she may write you a prescription for a dementia drug. Then the heartburn and dementia drugs combined cause you to develop constipation, and the next thing you know, you’re on another drug for that.
“You can end up on a long list of drugs that really were the result of one drug causing a problem,” says Chad Worz, chief executive officer for the American Society of Consultant Pharmacists.
As a senior care pharmacist, Worz spent years reviewing the medications of patients being admitted to assisted living facilities, often because their families thought they were experiencing dementia.
“We would discover it’s really not dementia, it’s delirium induced by their medications,” he says. “The last thing you want to do is put mom or dad in nursing home because you think they have dementia when all you need to do is take them off their meds.”
A push to ‘deprescribe’
In recent years, many primary care physicians and pharmacists have embraced a trend called “deprescribing” — the practice of regularly reviewing a patient’s medications to reduce the number of unnecessary and potentially harmful ones. There’s even a nationwide effort to reduce unnecessary prescriptions in long-term care facilities, since their residents are among those most at risk of prescription overload. One study of Medicare beneficiaries entering a skilled nursing facility found that they were prescribed an average of 14 medications each.
More than 2,000 long-term-care facilities across the country have so far joined a Society for Post-Acute and Long-Term Care Medicine campaign called Drive To Deprescribe, says von Preyss-Friedman, who is cochair of its work group. The goal is to reduce the number of medications taken by residents of long-term care by 25 percent.
When and how to ask for a medication review
No matter how many medications you take — but especially if you take more than five — it’s a good idea to ask your primary care doctor or pharmacist to go over them with you at least once a year, experts say.
Having a medication review is especially important after you are discharged from a hospital or rehab facility, since it’s common for patients to go home with myriad additional prescriptions, Levy says. She also suggests asking for a review if you lose or gain a lot of weight, if you are diagnosed with a new medical condition, or anytime you develop a new symptom.
“If something feels not quite right, always keep in mind it could be a medication effect,” Levy says.
When you go for your review, bring a complete list of all of your prescriptions and dosages, along with any over-the-counter medications and dietary supplements you take.
If you take a large number of prescriptions or have an especially complex medical history, you may want to reach out to an independent senior care pharmacist, also called a consultant pharmacist, who specializes in medication reviews for older adults. (Search for one in your area at www.helpwithmymeds.org.)
The goal is not just to reduce your number of pills, but also to make sure you are taking the best possible medications for your condition at the appropriate dosages for the fewest potential side effects, Worz says.
“When you get to four or five medications, it’s worth having someone look at it and make sure these medications work well together and you’re getting the benefits of them without the risk,” he says. “In my experience, it’s rare to find a patient who doesn’t have a medication problem we can correct.”
Tips to avoid prescription overload
Try non-drug alternatives. Before taking any new drug, consider whether there’s a way to try to treat the problem first without medication. Can you change your diet to control your diabetes or high blood pressure? Eliminate caffeine to help your insomnia?
Read the medication guide or insert. Pay special attention to harmful interactions and side effects, keeping in mind that they may not affect you right away.
Keep an up-to-date list of your medications. Make sure it includes over-the-counter drugs and supplements, which can cause dangerous reactions when mixed with certain prescriptions.
Stick to one pharmacy. Discounts may tempt you to transfer your medications to different pharmacies, but if you fill all of your prescriptions in one place, it’s easier for your pharmacist to spot possible interactions and safety issues.
Schedule a medication review. Sit down with your primary care doctor or pharmacist and talk about each of your medications and supplements — ask why you’re taking it, if there are safer ways to manage your symptom, and if it’s worth trying to go without.